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Home My WebLink About0138 LUMBERT MILL ROAD - Health 138 LUMBERT MILL, CENTERVILLE A � uu ° UPC 12534 ' No.2-153L R NAATINU.UN COMMONWEALTH OF MA.SSACHUSE17S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 138 Lumbert Mill Road Centerville Owner's Name: Mary Fowl _ —R i cP Owner's Address: Date of Inspection: 3 !3 aou6 Name of inspector:(please print) W i I 1 ' am E_ • Rob nson Sr Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuan7P'asses ion 15.340 of Title 5(310 CMR 15.000). The system: . Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i Page 2 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' 0 CERTIFICATION(continued) Property Address: 1 3 8 Lumbert Mill Road en ervi e Owner: Mary Fowler—Rice Date of Inspection: n Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S tern Passes: m 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: AJ/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: . w Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed-pipe(s)o d ru e to a broken settled or uneven distributio n box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 tans a year due to broken or obsui..-acd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rcmovcd ND explain: Page 3ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Lumbert Mill Road Centerville Owner: Mary Fowler—Rice Date of Inspection: i 3 00 C. Further Evaluation is Required by the Board of Health: / V/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic.tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well•• Method used to determine distance ••This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• 1 3 8 Lumbert Mill Road Centerville Owner: Mary Fowler—Rice Date of Inspection: /3 oc D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes 'N V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ondin of effluent to the surface of the ground or surface waters due to an overloaded or — P g gr i / clogged SAS or cesspool gSl Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool _ �Jc Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow J Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface / water supply. Any portion of a cesspool or privy is within a Zone 1 of a.public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private eater ° supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and (lie presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria ° are triggered.A copy of the analysis must be attached to this forma o- Nl7 (Yes/No)The system fails. 1 have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of u Health to determine what will be necessary to correct the failure. s E. Large Systems: /v To be considered a large s jst the system must serve a facility with a design now of 10,000 gpd l0 15,000 ° gPd- You must indicate either"yes"or"no"to each of the following: (71te following criteria apply to large systems in addition to the criteria above) E yes no the system is within 400 feet of a surface drinking water supply b _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped m Zone 11 of a public water supply well If you have answered"yes"to any question in Section E dte system is considered a significant threat,or answered "yes"in Section D above the large system has fatted.The trxn�ar operator of arty large system considered a a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.304.The system owner should contact the appropriate regional once of the Department. � G 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 3 8- Lumbert Mill Road Centerville Owner: Mary Fowler—Rice Date of Inspection: 3 i 3 ac06 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No/ _ �✓ .Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in'the previous two week period? _ J Have large volumes of water been introduced to the system recently or,as part of this inspection?. J _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) J _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? J Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? J — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes .no _ Existing information.For example,a plan at the Board of Health. . ^.s e 4 r 0WN e, 30119 vF j4ek lK /Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] ' S Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 138 Lumbert Mill Road Centerville Owner: Mary Fowler-Rice Date of Inspection: / 00 _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): •3 " DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -01) 6Pa Number of current residents:. Does residence have a garbage grinder(yes or no): jVa Is laundry on a separate sewage system(yes or no):n/0 [if yes separate inspection required] Laundry system inspected(yes or no): /jvA Seasonal use:(yes or no): ,V Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5 — 66, 000 Sump pump(yes or no):AL 2004 — Last date of occupancy: C.,.,frcn+ COMMERCIAIANDUSTRIAL /\//A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancyluse: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_,/jp If yes,volume pumped:_gallons--How was quantity pumped deteru"iined? Reason for pumping: TY t OF SYSTEM ✓✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be ob_tained from system owner) - -Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):— 6 I'agc 7 of I I OFFICIAL INSPECTION FORM—NO'T FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:1 38 Lumbert Mill Road Centerville Owner: Mary Fowler—Rice Date of Inspection: BUILDING SEIVER(locate on site plan) Depdn below grade: all Materials of construction:_cast iron V140 PVC_other(explain): Distance Got,private water supply well or suction lute: Comments(on condition of joints,venting,evidence of leakage,etc.): eA�+s wa-t tN �oor9 Cvne�r}iaN yea+� wus yyotA yo Scf�s eF L'"4e SEPTIC TANK: ��(locate on site plan) Depth below grade: // � Material of construction: ✓Conctcle_metal fiberglass�ol)•etltylene _othcr(explain) — If tank is metal list age:_ Is age confinned•by a Ceniftcate of Compliarue(yes or no): certificate) _(attach a copy of Dimensions:_ loaD (,Q//,45 Sludge depth: /,9r1 Distance from top of sludge to bottom of outlet tee or bank: aS Scunt thickness: 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of seun►to bottom of outlet tee or baffle: 7 3 f1 f low were dimensions determined: 001pned Cd✓z< rid *aw 1"e,:3c/rWc//�7 Comments(on pumping reconunendalions,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 1u1� does .1yDt weed }v &e Cftif�d dt 7�,s -l-i.�,P. 1N(e-�a�o� o✓clef 1�e1 rn C-/- G(� rn Gb�p Co.tc(7fon . je ri 1� c Irv .i4�� 5Ovnc�. GREASE TRAP: 41�to on site plan) Depth below grade:_ Material of construction:_concrete—metal fiberglass�}nolyethylene_outer (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or battle: Distance front bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Conuncnts(on pumping reconlntendalions,inlet and outlet(cc or bank conditiva, structural integrity, liquid lcvcls as rclalcd to outlet im'cn,evidence of leakage,cic.): 7 'age g of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Lumbert Mill Road Centerville Owner: Mary Fowler-Rice Date of IospColon: 311319 co TIGHT or HOLDING TANK:. (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:—concrete_rectal_fiberglass___polyethyleneother(explaui): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order.(),cs or no):— Date of last pumping: Comments(condition of alarm and float switches,ctc.): DISTIUBUTION BOX:Zif present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert: 0 it Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of IcakaSc into or out of box,ctc.): p-�� !*✓d uAa( t.v SJO 04 $lids e46!�yoJC� b 61?( is _"J's+ t^ern 1—k1-er E'-Gs p)� bp1�6nn a. v�-1laf. PUMP CUANIBER:4A(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): — Conunents(note condition of pump chanmber,condition of pumps and appurtenances, etc.): Page 9 of 1 I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Lumbert Mill Road Centerville Owner: Mary Fowler-Rice Date of Inspection:_ 3//3 f pooh SOIL ABSORPTION SYSTEM(S /AS): ✓ (locate on site plan,excavation-not required) If SAS not located explain why: Type r leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length:_ ) - 33`�(' /1` t oi� y k4,yh Cu zi+y leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): SG 3/ L'"S l�rY� .va , �N of hy�6r��1,� ,/Wl i/QS��c7hn ✓k5 Norv,+�( �f ,�ISPIc�,a 4 TPSr 6%le ,-4s JV4 nN e.re ')� SAS, '4 Nhc inStl�r� ind� Sh�< fan,c otr ply, CESSPOOLS: NIA(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:..- (locate on site plan) fi Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Lumbert Mill Road Centerville Owner: Mary Fowler—Rice Date of Inspection: 3 3 aoo� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A C) 1 0 1? EA OF H ousF A N l� A -1 Ib' L3 -a - 13 ` _ II A -.3= 33' 8- 3= Imo- 33 ' I SA5 27 s' 10 Page l l of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Lumbert Mill Road Centerviiie Owner. Mary Fowler—Rice Date of Inspection: 3��9aa� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: �'�h l//o✓iy{w� �c i t ie,s PSb�SHey1 t�/ CteCPdsi.o t3W N J� ns/x 5/eune�wu / 11 No. Fee 6 1 0!�Y; a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Oioponl *p6tem Construction Permit Application for a Permit to Construct q/Uepair )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot NoA38 Owner's Name,Address d�Teell.No. O O _�s Assessor's Map/Parce m fVk1r Installer's Name,Addrpss, and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms--' Lot Size*(X? I_sq.ft. Garbage Grinder(AJO Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank t eM Type of S.A. . N1 GA Description of Soil t I�1lZ Natgreeoof Repairs T Alterations(Answer when app cableA Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titk 5 of the Environmental Code and not to place the system in operationuntil Certifi- cate of Compliance has been is lth. Signe a Date Application Approved by Date Application Disapproved for the following reasons Permit No. YrIallllrl Date Issued d' .terry !� .....��' ✓ No. Fee - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes z. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Btsspaal *pgtem Construction Permit Application for a Permit to Construct epairy,,,)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No1�6 r , -��M 11 rn I u_� Owner's Name,Addressd�Tel. ^No. � l Xi ' 1,�� Assessor's Map/Parcel Installer's Name,AddNss-, d Tel.No. Designer's Name,Address and Tel.No. Type of Building: "Dwelling No.of Bedrooms 3 Lot SizeltQb� 1 sq.ft. Garbage Grinder KJQ Other Type of Building �.IC`� No:of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date . Number of sheets Revision Date Title Size of Septic Tank- Type of S.A. C \ t rrrr�t Description of Soil — y � Na re of Repairs or Alterations(Answer when Ia p icable) T v 4 5v G - Date last inspected: Agreement: The undersigned agrees to ensure the constructo and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti*5 of the Environmental Code and not to place the system in operatio until a Certifi- cate of Compliance has been is u alth. cr Signe n. Date Application Approved by Date Application Disapproved for the following reasons ar Permit No. fr Date Issued —————————————-------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO CERT ,,that the On- $ey�.age Dis o al System Constructed( � )Repaired( )Upgraded( ) Abandoned( )by / at t o ) I - iasbetm constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 1 Designer r The issuance of this it ?4 n t' es epns"ed as a guarantee that th sys�m will fOction a� eesigA /� Date Inspector v ''A U 1! , ,,C ----/—'`-------- ------ --- ——— — —— --- No. — Fee THE COMMONWEALTH OF MASSACHUSETTS 7 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5pogar *pgtem (Con5tructiou Permit Permission is hereby gray"t Con truct( ) pair( Upgr de(a )Abando X, System located at and as described in the above Application for Disposal System Construction Permit.The applicadrecogniz his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructiop must be c m leted within three years of the date of is p. t. ce3 Date:' Approved by /k_3 � v 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, 1u1%)�M �, hereby cert' that t e application for disposal works construction permit signed by me dated concerning the l 0 pr property located at ( `� meets all of the. following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS 1 and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the ro ed p pos septic system • There are no private wells within 150 feet of the proposed septic system r • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma.�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation L +the VLA X. High G.W. Adjustment �E DIFFERENCE BETWEEN A and Bj _ I SIGNED : DATE: C( (Sketch proposed plan of system on back]. q:health folder,cent 33 ` l� 1 k 519 r TOWN OF BARNSTABLE Q� LOCATION l�� UZ�� I 1 t�U�_ SEWAGE # ^ i� VILLAGE C"S=Xh1 (sC ASSESSOR'S MAP &LOT `- INSTALLER'S NAME&PHONE NO. 11 V l �T ONi SEPTIC TANK CAPACITY 100 6 LEACHING FACILITY: (type): X L C� C F `gmA, NO.OF BEDROOMS BUILDER OR OWNE PERMITDATE: Z COMPLIANCE .DATE: Separation Distance Between the; Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility,.(If.any wetlands exist within 300 feet of leaching facility) Feet Furnished by 96 l_1rJ� M q O - 17 2765 G-S- E �1 = a r -- TOWN OF BARNSTABLE LOCATION SEWAGE # ` VILLAGE� ��. ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. �� SEPTIC TANK CAPACITY r LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNE PERMTTDATE: - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist Feet j on site or within 200 feet of leaching facility) j Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 5.01 _ 2:_QQ9, Q�Q Ll21Z) -� O --- _